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Radiological Manifestations of Reiter's Syndrome

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Radiological Manifestations of Reiter's Syndrome Ann Rheum Dis: first published as 10.1136/ard.38.Suppl_1.12 on 1 January 1979. Downloaded from Ann. rheum. Dis. (1979), 38, Supplement p. 12 Radiological manifestations of Reiter's syndrome WILLIAM MARTEL From the University of Michigan Hospital, Michigan, USA Reiter's syndrome (RS) presents with a broad Table 1 Distribution of arthritis and radiological spectrum of radiological manifestations. Although features in 36 cases of Reiter's syndrome there is an overlap with other connective tissue Distribution No. ofcases diseases134, 214, 221, 248, 286 certain features appear to Joints of upper extremities 11 be characteristic, particularly when present in Joints of lower extremities 30 combination. This report concerns the radiological Forefoot 18 Heel 18 findings in 36 patients with RS. They are compared Interphalangeal great toe 8 with the radiological manifestations of rheumatoid Feet more than hands 16 arthritis (RA), ankylosing spondylitis (AS), and Sacroiliac arthritis 26 Symmetric 17 psoriatic arthritis (PSA). Asymmetric 6 Unilateral 3 Spondylitis 16 Patients and methods Atypical for ankylosing spondylitis 14 Typical for ankylosing spondylitis 2 Focal sacroiliitis 4 by copyright. Records of 36 patients were selected from the files of Periosteal bone apposition the department of radiology, University of Michigan (appendicular joints) 26 Medical Center, on the basis of previously docu- mented positive radiological findings. The records were then reviewed to confirm the clinical diagnosis of RS. For the purpose of this study the diagnostic affected in only 11. The most common site of criteria were (1) objective evidence of arthritis of the involvement was the foot, particularly the metatarso- appendicular joints, and (2) two of the following: phalangeal joints and heels. The posterosuperior and mucocutaneous lesions, conjunctivitis, and urethritis. posteroinferior aspects of the calcaneus were These features had to have occurred within six affected (Figs 1, 2), particularly the latter, at the weeks of one another. It was recognised that the attachment of the plantar aponeurosis. The inter- http://ard.bmj.com/ arthritis in patients with RS may be limited to the phalangeal joint of the great toe was affected in eight spine, but because of the difficulty in evaluating such instances and this appeared to be relatively selective arthritis, particularly in the early stages, such cases in three (Fig. 3). Occasionally there was severe were not included in the study. destruction of some metatarsophalangeal joints but Radiological joint surveys of the spine and adjacent ones seemed completely spared. The hips appendicular joints were available in 20 cases. Six were affected in one case bilaterally. Arthritis was others had had fairly complete radiological evalua- more extensive in the feet than the hands in 16 cases. on September 29, 2021 by guest. Protected tions, although not all joints were included. Films of The terminal interphalangeal joints of the hands were the lumbosacral spine were available in all cases. affected in two patients and only one such joint was Many patients had been followed-up clinically for affected in both. The sacroiliac joints were affected in several years, affording opportunities for extended 26 patients and the spinal column in 16. Focal periods ofradiological observation. sacroiliitis near a sarcoiliac joint was noted in four cases. Radiological features REGIONAL OSTEOPOROSIS Significant radiological features are summarised in This was a striking finding in the early stages of the Table 1. disease in three patients. It was limited to the foot in two cases (Fig. 4) and to the hand in one. A frequent DISTRIBUTION feature was relative absence of osteoporosis despite Joints of the lower extremities were affected in 30 extensive joint destruction. This was particularly cases whereas joints of the upper extremities were evident in the foot. Ann Rheum Dis: first published as 10.1136/ard.38.Suppl_1.12 on 1 January 1979. Downloaded from L Features andprognosis Suppl. p. 13 Soft-tissue swelling, presumably non-specific due narrowing of the interosseous space. Bone destruc- to joint effusion and synovitis, was common in the tion occasionally appeared as discrete marginal ankle, knee, and joints of the hand, wrist, and foot. erosions within the joint at the chondro-osseous junctions ('bare areas') (Fig. 5) or as loss of cortical DESTRUCTION OF ARTICULAR CARTILAGE definition within and adjacent to the joints. Sites of This was common and manifested by uniform bone erosion were often blurred by coexistent by copyright. Fig. 1 Progressive clacaneal erosion. Early erosion in May 1971 (arrow) was more extensive in September 1971 wit,A blurred margins due to associated minimal reactive bone presumably formation. http://ard.bmj.com/ on September 29, 2021 by guest. Protected Fig. 2 Note erosion at posterosuperior aspect of Fig. 3 Relatively selective arthritis ofinterphalangeal calcaneus (arrow) and extensive periosteal bone joint ofgreat toe with severe joint destruction and apposition at inferior aspects ofcalcaneus, especially reactive bone formation. Note soft tissue swelling of posteriorly, and cuboid. Calcaneocuboidjoint 4th and 5th toes with erosion ofdistal interphalangeal relatively intact but cuboidmetatarsaljoint affected. joint ofthe 4th. Ann Rheum Dis: first published as 10.1136/ard.38.Suppl_1.12 on 1 January 1979. Downloaded from Suppl. p. 14 Annals of the Rheumatic Diseases Fig. 4 Osteoporosis, right foot, associated with minimal generalised soft-tissue swelling. by copyright. http://ard.bmj.com/ on September 29, 2021 by guest. Protected Fig. 5 Arthritis limited to proximal interphalangeal K...: ::::.: ::: :- .-- joint. Note fusiforn soft-tissue swelling, uniform loss of cartilage, and marginal erosions. Erosions partially Fig. 6 Severe destructive arthritis and subluxation of obscured by periosteal bone apposition. multiple joints with sparing of4th metatarsophalangeal joint. Note involvement of interphalangeal joint of great toe and relative lack ofosteoporosis. periosteal bone apposition. Large subchondral PERIOSTEAL BONE APPOSITION cyst-like lesions were not seen. Severe destructive This was seen in the appendicular skeleton in 24 arthritis with extensive bone resorption and sub- cases, was often exuberant and fluffy during the luxation ('arthritis mutilans' or Launois's deformity) active stage of inflammation, and was typically was observed in three cases. All involved the contiguous to affected joints (Fig. 7). Later in the metatarsophalangeal joints. One or more joints may disease such bone characteristically appeared linear be 'skipped'-that is, completely spared (Fig. 6). and compact, giving the cortex a 'thickened' Ann Rheum Dis: first published as 10.1136/ard.38.Suppl_1.12 on 1 January 1979. Downloaded from L Features andprognosis Suppl. p. 15 appearance (Fig. 8). Focal bone apposition, adjacent to a previously affected joint, was at times the only indicator of prior inflammation. This feature was often subtle (Fig 9). SACROILIAC ARTHRITIS This occurred in 26 cases and was symmetrical in 17. In the latter it was indistinguishable from the radiological changes of ankylosing spondylitis (Fig. 10). The appearance depended on the stage of the disease, with the early lesion often appearing as an indistinctness ofthe subchondral cortices (Fig. 11). Reactive sclerosis in the adjacent bone varied in degree. Bc!nv ankylosis was common. In six patients sacroiliac arthritis was clearly asymmetric and in three it was unilateral. In three cases the asymmetry or unilaterality persisted for several years (Fig. 12). In four patients there was a focal sclerosis and hyperostosis, involving both sacrum and contiguous Fig. 7 Arthritis offirst metatarsophalangealjoint associated with bone erosion andperiosteal bone by copyright. apposition ofmetacarpal and, to lesser extent, phalanx (arrows). Note minimal uniform narrowing of interosseous space ofthis joint. http://ard.bmj.com/ on September 29, 2021 by guest. Protected ~~~~~~~~~~~~~ Fig. 8 Destructive arthritis, right fourth metatarsophalangealjoint, with deformity and widening ofbones due to periosteal bone apposition in a child. Note involvement offirst tarsometartasaljoint with marginal bone erosions andlack ofosteoporosis in right foot. Ann Rheum Dis: first published as 10.1136/ard.38.Suppl_1.12 on 1 January 1979. Downloaded from Suppl. p. 16 Annals of the Rheumatic Diseases ilium, adjacent to the cranial margin of the joint (Fig. 13). This appeared to be analagous to the hyperostoses in the appendicular skeleton and vertebral bodies. SPONDYLITIS Two of the 16 cases with spinal involvement showed changes indistinguishable from those of ankylosing spondylitis. However, the others had a distinctive appearance characterised by asymmetric bony bridges between contiguous vertebral bodies, usually involving the lateral aspects (Fig. 14). These often resembled massive syndesmophytes, appearing to arise from the vertebral body proper, and often there were several such bone formations which were non-continuous. The vertebral body margins where these arose occasionally showed deformity and sclerosis, suggesting that the bone formation reflected vertebral periostitis rather than inflamma- tion of the discovertebral joints. Furthermore, the intervertebral discs were often ofnormal height at the affected levels. Although there was squaring of the vertebral by copyright. bodies in some cases the anterior surfaces of the vertebrae tended to be spared, even at those levels
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